Find the Best Muscle Relaxants for Pain

The skeletal muscle relaxants are a diverse set of drugs that are used for treating
muscle spasticity or spasms, which can cause pain and interfere with your functional
ability. Spasticity, or having stiff, rigid muscles with exaggerated reflexes,
generally lasts a long time. It arises from conditions affecting the brain and/or
spinal cord, such as cerebral palsy, multiple sclerosis, and stroke. Muscle spasms,
on the other hand, are usually temporary and are associated with conditions
affecting the muscles, bones, and associated structures, such as tension
headaches, back or neck pain, and fibromyalgia.

While these are widely prescribed drugs, the evidence supporting the effectiveness
of the nine available muscle relaxants is sparse, and some studies are of
questionable quality. Many of the avai lable studies are old and do not meet current
standards. While the available evidence indicates that the drugs can help
relieve symptoms, the poor quality of the research makes it difficult to draw firm
conclusions about whether any one drug is superior to the others. Also, most of
these medicines cause sedation as a side effect, and some of them pose a risk of
serious problems, such as liver toxicity and addiction.

Muscle spasticity

Taking into consideration all of the evidence on muscle relaxants for spasticity,
our Best Buy pick is:

Generic baclofen tablet

Baclofen costs between $27 and $60 for a 30-day supply, so you could save a
significant amount of money over some of the more expensive brand-name
muscle relaxants, which can cost $200 to up to $486 a month. If you are unable
to tolerate baclofen, we recommend trying generic tizanidine.

Muscle spasms

If you have a musculoskeletal problem-such as headache, back or neck pain-
fibromyalgia or other conditions that cause spasms that have not responded to
nondrug therapies, then pain relievers such as acetaminophen (Tylenol and generics)
or non-steroidal anti-inflammatory drugs, or NSAIDS (aspirin, ibuprofen, naproxen) are a reasonable first option. The muscle relaxants have not been found
to be any better than these painkillers for providing relief. Plus, the muscle relaxants
can cause sedation and other serious side effects. If you can't tolerate acetaminophen
or NSAIDs because of kidney or liver problems, bleeding ulcers or heart
issues, then you may want to consider trying a muscle relaxant.

If you and your doctor have decided to try a muscle relaxant to treat muscle
spasms, taking all of the evidence into consideration, we chose the following as
a Best Buy:

Generic cyclobenzaprine tablet

Cyclobenzaprine is supported by the strongest body of evidence. Also, it is
available in a generic form that costs $8 to $15 for a seven-day course, which
makes it one of the least expensive muscle relaxants and significantly less
expensive than brand-name ones that can run more than $100. If cyclobenzaprine
is not effective or causes you side effects that you can't tolerate, you could
try methocarbamol or chlorzoxazone, both of which are available as inexpensive
generics. We recommend avoiding carisoprodol (Soma) because it is associated
with a high risk of abuse and addiction potential not seen with other skeletal
muscle relaxants.

In addition to sedation, the most common side effects associated with muscle
relaxants include weakness or fatigue, dizziness, and dry mouth.

Welcome

This report compares the effectiveness, safety, and cost of a class of
medications known as skeletal muscle relaxants. The term skeletal
refers to the fact that there are three types of muscles in the body:
skeletal, smooth, and cardiac. This group of drugs generally works
only on the skeletal muscles, which power the movements of the
skeleton. This is a diverse set of drugs that don't share a chemical
structure or have the same mechanism of action. They are grouped
together because they have been approved by the U.S. Food and Drug
Administration (FDA) for treating similar conditions and disorders.

The result is that each medication may affect you-in terms of benefits
and side effects-quite differently. In fact, many people are
unaware that muscle relaxants are approved by the FDA to treat one
of two very different types of underlying conditions: muscle spasticity
due to conditions affecting the brain and/or spinal cord, such as
cerebral palsy, multiple sclerosis, and stroke; and muscle spasms from
conditions affecting the muscles, bones and associated structures,
such as tension headaches, back or neck pain, or fibromyalgia.
Spasticity is often a chronic condition that may last for years.
Conversely, muscle spasms generally don't last very long, or may occur
only on occasion.

Although some of the muscle relaxants are used to treat both conditions,
nearly all of the muscle relaxants have only been well-studied
for one condition or the other.

Another issue that complicates the evaluation of muscle relaxants is
that many of the available studies are old and don't meet current standards
for quality research. And because many of the muscle relaxants
are older drugs that are available as generic medicines, there is little
incentive for drug manufacturers to sponsor new studies. The result is
that despite the widespread use of muscle relaxant drugs, the evidence
among several drugs is sparse or inadequate for consumers or their
doctors to compare benefits and harms.

There are nine muscle relaxants available in tablets or capsules. As you
can see in Table 1 all but a few are available in generic forms.
A few are available in combination with aspirin, codeine, and/or caffeine.

Muscle relaxants are just one of the many types of medications that
can be used to treat spasticity or spasms. Other medications that are
sometimes used as muscle relaxants but don't carry FDA approval for
this purpose include benzodiazepines, such as diazepam (Valium and
generics), and botulinum toxin (Botox). Analgesics, such as acetaminophen
and NSAIDs, are considered first line therapy for muscle spasms,
and they may help relieve the pain associated with spasticity. Opioids, 4
such as codeine and morphine, are used as a last resort for treating
these conditions because they can have dangerous side effects. Quinine
has been used for treatment of muscle cramps, but you should be aware
that the drug's labeling warns against this use because the medicine
can have serious and life-threatening side effects.

Table 1. Muscle Relaxants

Generic Name

Form

Brand Name

Available as Generic?

Baclofen

Tablet

Lioresal

Yes

Carisoprodol

Tablet

Soma

Yes

Cyclobenzaprine HCl

Tablet

Fexmid,

No

Tablet

Flexeril

Yes

Continuous-release capsule

Amrix

No

Chlorzoxazone

Capsule

Parafon Forte DSC

Yes

Dantrolene

Capsule

Dantrium

Yes

Metaxalone

Tablet

Skelaxin

No

Methocarbamol

Tablet

Robaxin, Robaxin-750

Yes

Orphenadrine citrate

Tablet

Norflex

Yes

Tizanidine

Tablet and capsule

Zanaflex

Yes

Combination products

Carisoprodol + aspirin

Tablet

Carisoprodol CPD

Yes

Carisoprodol + aspirin + codeine

Tablet

Carisoprodol CPD with codeine, Soma compound with codeine

Yes

Orphenadrine + aspirin + caffeine

Tablet

Norgesic Forte

Yes

Some muscle relaxants can also be given intravenously or directly
into the spine. However, this report focuses only on tablet or capsule
(oral) muscle relaxants.

You may also want to talk with your doctor about other nondrug treatments
for spasticity or muscle spasms. These include heating pads, exercise
therapy, manipulation or mobilization, biofeedback or progressive
relaxation, massage, yoga, and acupuncture.

What is the difference between muscle spasticity and muscle spasms?

Muscle spasticity is caused by damage to the brain or spinal cord.
Normally, nerves in the brain and spinal cord help keep the muscles
relaxed when you aren't using them. Conditions that affect the spinal
cord or brain, such as cerebral palsy, multiple sclerosis, and stroke, can
interfere with normal muscle relaxation, resulting in involuntary muscle
spasms that can be very painful and impair your ability to walk,
sleep, work, or just function normally. The muscles can also become
excessively tense (hypertonia) and have overactive or overresponsive
reflexes (hyperreflexia). This combination of symptoms is called the
upper motor neuron syndrome. Severe cases can result in profound disability,
including an inability to straighten out joints.

Among the muscle relaxants, only baclofen, dantrolene, and tizanidine
are FDA approved for the treatment of spasticity. These three medications
act by different mechanisms: Baclofen and tizanidine are thought
to block certain nerve signals that "tell" muscles to contract, while
dantrolene directly inhibits muscle contraction by decreasing the
release of calcium, which is necessary to trigger muscle contraction.

Muscle spasms, on the other hand, occur in conditions which affect
the muscles, bones, and associated tissues. These include headache,
back or neck pain, and fibromyalgia or other conditions that cause
chronic pain in the muscle tissues due to local factors involving the
affected muscle groups, not damage to the nerves in the brain or
spinal cord. With muscle spasms, unlike muscle spasticity, the muscles
don't become excessively tense or show overactive reflexes. At the
same time, fibromyalgia, headache, back or neck pain can be very
painful and reduce your ability to function, and they are much more
common conditions than having muscle spasticity.

What Are Muscle Relaxants and Who Needs Them?

Six of the muscle relaxants are FDA approved for
treatment of muscle pain: carisoprodol, chlorzoxazone,
cyclobenzaprine, metaxalone, methocarbamol,
and orphenadrine. (Several trials have evaluated
whether tizanidine is effective for treating
musculoskeletal conditions, but it is only FDA
approved for treatment of spasticity.) These drugs
have very different pharmacological structures.
Cyclobenzaprine is closely related to tricyclic antidepressants.
Carisoprodol is broken down in the
body into meprobamate, which is a drug classified
as a controlled substance by the U.S. Drug
Enforcement Agency due to its potential for addiction
and abuse. Methocarbamol is structurally related
to mephenesin, an older muscle relaxant that is
no longer used because it was associated with blood
clots and other dangerous side effects. Orphenadrine
is derived from the antihistamine diphenhydramine
(Benadryl), but generally causes more intensive side
effects, such as dry mouth, sedation, urine retention,
and increased eye pressure.

We don't know exactly how most of the muscle
relaxants reduce muscle spasticity or spasms.
Dantrolene, which blocks a key step involved in
triggering muscle contraction, appears to have the
most direct effect on the muscles. Other muscle
relaxants appear to have more indirect effects. For
example, baclofen blocks certain nerve signals to
muscles, while tizanidine may cause effects that are
similar to the high blood pressure drug clonidine.
The sedative effect that most muscle relaxants
cause may also be important. Many experts think
that much of the benefit of these drugs may come
from the sedation they induce in people.

When choosing among the many muscle relaxants,
your doctor will consider whether you have muscle
spasticity due to cerebral palsy, multiple sclerosis,
stroke or other conditions that affect the brain
and/or spinal cord; or muscle spasms tension
headaches, back or neck pain, fibromyalgia or other
conditions associated with chronic pain in muscle
tissues.

Other factors your doctor will take into account
include the severity of your symptoms, and the risk
of sedation, a concern for pilots, drivers, and people
in other positions involving the use of heavy or
dangerous equipment. Your doctor will also consider
the side-effect profile of the different drugs-for
example, the risk of liver toxicity or potential for
addiction-and how you responded to muscle
relaxants in the past if you previously took any.
When you first start on one of these drugs, take the
first dose at a time when you do not have to work
or go anywhere, such as in the evening or on a
weekend, to see how much sedation you experience.
It is also a good idea to completely avoid
alcohol while taking these medicines.

Muscle spasticity is generally considered a chronic
condition, so muscle relaxants are often used on a
scheduled, around-the-clock basis. But they also may
be given as needed when the spasticity flares up. The
dose that is used typically depends on whether the
spasticity is continuous or is more episodic.

For treating muscle spasms due to conditions like
back or neck pain, muscle relaxants are typically
used on an as-needed, short-term basis. Although
these medications are sometimes given long-term
for treating these kinds of conditions, there is little
evidence to show that chronic use actually
improves symptoms.

Muscle Spasticity

Muscle spasticity caused by brain or spinal problems
is difficult to measure. Standardized scales to assess
it have been developed, but some experts think that
they measure muscle tone more than spasticity. More
importantly, measurements based on these kinds of
scales may not correlate well with your symptoms or
functional ability. The bottom line is that if you have
an upper motor neuron syndrome, your need for a
muscle relaxant should be based on how much pain
and functional disability is caused by your spasticity,
not solely on a spasticity score.

Muscle Spasms

Many conditions that cause spasms, such as backache
and headaches, are mild or self-limited, and don't require specific therapy or
drugs. In other cases, short courses of simple pain relievers,
such as acetaminophen (Tylenol or generics) or NSAIDs, such as
aspirin, ibuprofen (Advil and generics), or naproxen (Aleve
and generics), are enough to bring relief. So you may want to
try one of those nonprescription pain relievers first. Studies that
compared simple pain relievers with muscle relaxants generally
found little difference in how well they improved pain or
function-but the muscle relaxants were associated with much
more sedation.

In certain situations, however, muscle relaxants can be a preferred
option. Some people may not be able to take acetaminophen
if they have certain conditions, such as liver disease. And
those with a history of bleeding ulcers or heart problems may
not be able to take an NSAID. Others may find that their muscle-spasm
symptoms make it difficult to sleep, so the sedation
associated with the muscle relaxants is not necessarily an
undesirable side effect. In some cases, muscle spasms may persist
despite a trial of a simple pain reliever. In all these situations,
a trial of a muscle relaxant may be appropriate. Most
acute spasm episodes are limited to a few hours, days or weeks,
and a short course of a muscle relaxant may be all you need to help you get
through that period.

If the spasms last longer than a few weeks, you
should discuss with your doctor whether you are
truly benefiting from the muscle relaxant and
whether it should be continued, or if alternative
therapies should be tried.

Choosing a Muscle Relaxant - Our Best Buy Picks

Studies have found that muscle relaxants can relieve
pain and improve symptoms associated with spasticity
or spasms. (We discuss the evidence in detail
beginning on section 4.) Some of the drugs in this
class are better studied than others, so we favor
those medicines because more is known about their
effectiveness. All these drugs can cause side effects,
including some dangerous ones, such as liver toxicity
and addiction. But these issues have not been rigorously
studied, so it's difficult to draw any conclusions
about whether one muscle relaxant is superior
to the others when it comes to safety. Tables 3 and 4
provide an overview of important
considerations for each muscle relaxant.

Muscle Spasticity

Taking all the evidence on skeletal muscle relaxants
into consideration, there are three medications that
have been found to be effective for spasticity. Dantrolene
is not a first-line drug because of its potential for
serious liver injury. This leaves baclofen and tizanidine.
Both of these medications are available in generic
form, and as you can see from the Cost Comparison of Muscle
Relaxants on the Drug Comparison tab,
a month's supply of baclofen costs $27 to
$60, depending on the dose, and is less expensive
than tizanidine, which costs $72 to $81. So, for
patients with spasticity we recommend:

Generic baclofen tablet

Baclofen is FDA approved for treating spasticity
due to multiple sclerosis and spinal cord injuries or
diseases. Several studies support its effectiveness
for treating spasticity associated with cerebral
palsy, and there's no reason to think it wouldn't
work for alleviating spasticity in general.

If you are unable to tolerate baclofen, we recommend
trying tizanidine. Dantrolene should only be
used as a last resort due to the serious liver risks
associated with it.

Muscle Spasms

If you have a musculoskeletal condition, such as headache, back or neck
pain, fibromyalgia or other conditions, that causes spasms that have not
responded to nondrug therapies, then nonprescription
pain relievers, such as acetaminophen (Tylenol or
generics), or NSAIDs (aspirin, ibuprofen, naproxen)
are a reasonable first option. As we've previously
stated, the muscle relaxants have not been found to
be any better than these for providing relief, and the
relaxants can cause sedation and other serious side
effects. But if you can't tolerate acetaminophen or
NSAIDs be cause of liver problems, bleeding ulcers or
heart issues, then you should discuss with your doctor
whether trying a muscle relaxant would be appropriate
for your situation.

If you and your doctor have decided to try a skeletal
muscle relaxant for a musculoskeletal condition,
based on all available evidence, we chose the following
as a Best Buy:

Generic cyclobenzaprine tablet

Although several muscle relaxants appear to be effective
for musculoskeletal conditions, our pick is based
on the fact that cyclobenzaprine is supported by the
strongest body of evidence. Also, it is available in a
generic form that costs $8 to $15 for a seven-day
course, which makes it one of the least expensive
generic muscle relaxants and significantly less expensive
than brand-name relaxants that can run more
than $100. (See Cost Comparison of Muscle Relaxants
on the Drug Comparison tab for cost
comparison.) In addition, the 5 mg pill may be as
effective as a 10 mg pill and have fewer side effects.
Although a sustained-release formulation of cyclobenzaprine
is available, it is much more expensive-at
around $91 for a seven-day supply-and hasn't been
found to be more effective than the standard-release
formulation. For most people, the substantial increase
in cost isn't worth the greater convenience of once-aday
vs. three times daily dosing.

If cyclobenzaprine is not effective or causes side
effects that you can't tolerate, you should switch to
another muscle relaxant. Methocarbamol and chlorzoxazone
are available as generics and cost less than
$15 for a 30-day supply. Keep in mind that the evidence
for both of these drugs is fairly limited.
Tizanidine, orphenadrine, and metaxalone are more
costly alternatives. Carisoprodol should be avoided if
possible. Although it is available as a generic that
costs about the same as methocarbamol and chlorzoxazone,
it is associated with abuse and addiction
potential not seen with other skeletal muscle relaxants.
Your doctor would need to assess whether
carisoprodol can be prescribed safely based on a number
of factors, including whether you have a personal
or family history of substance abuse or addiction, and
what other medications you are taking.

Table 2. Muscle Relaxants: Key Points

Generic Name and Dose

Brand Name

Comments/Special Notes

For treatment of muscle spasticity

Baclofen 5 mg, 10 mg or 20 mg three times daily

Lioresal

More weakness than tizanidine, but less dry mouth (similar sedation)

Generic form available

Tizanidine 2 mg, 4 mg, or 6 mg (usually given three times daily, up to 24 mg/day)

The Evidence

This section presents more detailed information on the effectiveness and safety of muscle relaxants.

This report is based on an analysis of the scientific
evidence on muscle relaxants. This systematic
review was published in 2005, and a literature
search was conducted to identify relevant new trials
published since then. More than 120 studies
were considered in the analysis, including 59 trials
of muscle relaxants for treating spasticity, 52 for
treating musculoskeletal conditions, nine systematic
reviews and three meta-analyses.

How Effective Are Muscle Relaxants for Treating Spasticity?

For muscle spasticity due to upper motor neuron
syndromes, the three FDA approved skeletal muscle
relaxants-baclofen, dantrolene, and tizanidine-generally
appear to be more effective than placebo
for improving symptoms in short-term trials (less
than 10 weeks in duration).

The other skeletal muscle relaxants, which are
approved for treatment of other muscle conditions,
have not been found to be more effective than
placebo for treatment of spasticity.

Even for baclofen, dantrolene, and tizanidine, it is
difficult to estimate your likelihood of improvement
because many of the studies had methodological
shortcomings; estimates were often imprecise
due to small sample sizes (frequently 10 to 40 subjects);
most of the studies used different (and often
unproven) methods to measure spasticity and evaluate
other outcomes; and there was some inconsistency
between trials, with some finding no benefits.
The few trials that evaluated effects on pain or
function reported no clear differences between
muscle relaxants vs. placebo, or inconclusive
results. The largest placebo-controlled trial of
baclofen found that 46 percent of the subjects
experienced improvement in flexor spasms on
baclofen compared with 16 percent on placebo
after five weeks of treatment. A relatively large and
well-conducted trial of tizanidine found that 28
percent of the patients who received this drug rated
their overall outcome as "very good" or "good"
after nine weeks compared with 14 percent of those
who were given placebo.

In trials that directly compare tizanidine and
baclofen, these drugs appear to be roughly equivalent
for improving symptoms associated with spasticity.

There is insufficient evidence to adequately assess
the comparative efficacy of dantrolene compared
with tizanidine or baclofen. However, as in the section
on side effects, dantrolene is not considered a
first-line drug because of the risk of serious, and
sometimes fatal, liver toxicity.

A number of trials have compared tizanidine, baclofen,
and dantrolene with diazepam, a benzodiazepine that
is often used (but not FDA approved) as a muscle
relaxant. Diazepam should be reserved as a last resort
because it can result in physical dependence, abuse, or
addiction, and it is classified as a controlled substance
by the U.S. Drug Enforcement Agency. In these trials,
the three skeletal muscle relaxants appear to be similarly
effective compared with diazepam.

There is insufficient evidence to determine if formulations
that combine a skeletal muscle relaxant
with another drug (such as aspirin, codeine, and/or
caffeine) are any more effective than the skeletal
muscle relaxant alone.

How Effective Are Muscle Relaxants for Treating Spasms?

The evidence on how well different muscle relaxants
work to relieve pain from spasms caused by
musculoskeletal conditions varies both in the quality
and quantity of studies done. Cyclobenzaprine
is the best studied of the skeletal muscle relaxants.
In over 20 trials, cyclobenzaprine was consistently
more effective than placebo on various measures of
pain relief, functional ability, and muscle spasm.

Although cyclobenzaprine was studied for a number
of musculoskeletal conditions, most trials
involved patients with acute back or neck pain and
lasted for a short-term period (less than four
weeks). A meta-analysis of 10 trials of cyclobenzaprine
vs. placebo to treat back or neck pain found
that after 10 to 21 days, patients reported improving
an average of about one point on 10-point pain
or function scales. The longest trial found that
cyclobenzaprine was no more effective than a
placebo in patients with fibromyalgia at six months
for likelihood of improvement. One trial found that
cyclobenzaprine at a dose of 5 mg three times daily
was as effective as cyclobenzaprine at 10 mg three
times daily, but with less sedation. The benefits of
a sustained-release formulation of cyclobenzaprine
appear similar to the nonsustained release formulation,
with the potential advantage of greater patient
convenience due to less-frequent dosing.

Tizanidine is only FDA approved for the treatment
of spasticity, but six studies have found it to also be
effective for spasms caused by musculoskeletal
conditions.

Carisoprodol and orphenadrine have been studied
less, with only four trials for each drug. The available
evidence indicates that both drugs are more effective
than placebo for spasms due to musculoskeletal conditions.

Chlorzoxazone and methocarbamol also appear to
be effective for treating muscle spasms, but the evidence
is limited to one trial for chlorzoxazone and
three trials for methocarbamol.

The evidence on metaxalone is mixed. Some trials
found no benefit compared with placebo, and others
found some benefit. So we can't draw a conclusion
about whether it is effective.

For dantrolene and baclofen, which are approved
for treatment of spasticity, the evidence of benefits
for spasms due to musculoskeletal conditions is
very limited (one or two placebo-controlled trials).

There is insufficient evidence from head-to-head
trials of different skeletal muscle relaxants for
spasms to determine whether any one is superior to
the others due to small numbers of trials for comparison
and either no clear differences between
drugs or methodological shortcomings in trials that
found differences. A number of trials compared
cyclobenzaprine to diazepam (a benzodiazepine)
with no clear differences found.

There is also insufficient evidence to determine if
formulations that combine a skeletal muscle relaxant
with another drug (such as aspirin, codeine,
and/or caffeine) are any more effective than the
skeletal muscle relaxant alone.

Safety and Side Effects of Muscle Relaxants

In general, reliable evidence is lacking on the comparative
safety of different skeletal muscle relaxants.
In almost all trials, there was little or no evidence of
rigorous adverse event assessment. One of the most
common side effects of these drugs is sedation. Most
patients experience some sedation with almost all
skeletal muscle relaxants, though estimates vary
substantially depending on how sedation is defined
and assessed. Table 4, below, lists the most common
types of side effects reported in research studies that
you should look for if you are taking a skeletal muscle
relaxant.

Table 4. Most Common Side Effects of Muscle Relaxants

Sedation or somnolence

Weakness or fatigue

Dizziness or lightheadedness

Dry mouth

In head-to-head trials that compared tizanidine to
baclofen for spasticity, both drugs were associated
with roughly equivalent rates of sedation in anywhere
from 20 percent to 80 percent of the
patients, depending on the trial. Other side effects
may be different, as most head-to-head trials of
these two medications found tizanidine more likely
to cause dry mouth and baclofen more likely to
cause weakness. Nonetheless, there was no evidence
that the overall rate of side effects (or side
effects severe enough to result in stopping the
drug) differs. Reversible elevations of liver tests
have been reported with tizanidine, though this
side effect usually doesn't cause any symptoms,
and serious or fatal liver injury appears extremely
rare. Other serious but rare side effects such as
seizures, serious withdrawal, and overdose have
been reported in case studies of baclofen.

There is insufficient evidence to judge the comparative
safety of other skeletal muscle relaxants in
patients with spasticity.

As in the case of spasticity, reliable evidence is lacking
on the comparative safety of different muscle
relaxants for musculoskeletal conditions. In almost
all trials, there was little or no evidence of rigorous
adverse event assessment. Nonetheless, most
patients will experience some sedation with almost
all skeletal muscle relaxants, though estimates vary
substantially (typically 20 percent to 80 percent)
depending on how sedation is defined and assessed.

There is insufficient evidence to judge whether any
one skeletal muscle relaxant is safer than the others
in patients with musculoskeletal conditions. Head-to-head
data are limited and don't show any clear
differences in risk of different side effects (or risk of
intolerable side effects resulting in stopping the
drug).

Although there is insufficient evidence to estimate
the comparative risk of abuse or addiction, almost
all reports of this complication have been in
patients taking carisoprodol. This may be because
carisoprodol is metabolized to meprobamate, a
drug controlled by the Drug Enforcement
Administration (DEA) because of its abuse and
addiction potential. Carisoprodol is not controlled
by the DEA, but some states control its use.

Other serious side effects appear rare and it is difficult
to estimate their relative frequency.
Tizanidine and chlorzoxazone have been associated
with rare cases of serious liver damage when used
for treating spasms.

One trial found that cyclobenzaprine 5 mg three
times a day was just as effective as 10 mg three
time a day, but was associated with fewer side
effects, such as sedation.

Age, Gender, and Race Differences

There is not enough relevant evidence from the
available studies to determine whether the muscle
relaxants have different efficacy or safety profiles
in younger or older people, different races, or men
and women.

Talking With Your Doctor

It's important for you to know that the information we present here is not meant to substitute for a doctor's
judgment. But we hope it will help you and your doctor arrive at a decision about which muscle-relaxant
medication and dose is best for you, if one is warranted at all, and which gives you the most value for your
health-care dollar.

Bear in mind that many people are reluctant to discuss the cost of medicines with their doctor, and that studies
have found that doctors do not routinely take price into account when prescribing medicines. Unless you
bring it up, your doctors may assume that cost is not a factor for you.

Many people (including physicians) think that newer drugs are better. While that's a natural assumption to make,
it's not true. Studies consistently find that many older medicines are as good as, and in some cases better than,
newer medicines. Think of them as "tried and true," particularly when it comes to their safety record. Newer drugs
have not yet met the test of time, and unexpected problems can and do crop up once they hit the market.

Of course, some newer prescription drugs are indeed more effective and safer. Talk with your doctor about the
pluses and minuses of newer vs. older medicines, including generic drugs.

Prescription medicines go "generic" when a company's patents on them has lapsed, usually after about 12 to
15 years. At that point, other companies can make and sell the drug.

Generics are much less expensive than newer brand-name medicines, but they are not lesser quality drugs.
Indeed, most generics remain useful medicines even many years after first being marketed. That is why more
than 60 percent of all prescriptions in the U.S. today are written for generics.

Another important issue to talk with your doctor about is keeping a record of the drugs you are taking. There
are several reasons for this:

First, if you see several doctors, each may not be aware of medicines the others have prescribed.

Second, since people differ in their response to medications, it is very common for doctors today to prescribe
several medicines before finding one that works well or best.

Third, many people take several prescription medications, nonprescription drugs, and dietary supplements
at the same time. They can interact in ways that can either reduce the benefit you get from the drug or
be dangerous.

And fourth, the names of prescription drugs-both generic and brand-are often hard to pronounce and
remember.

For all these reasons, it's important to keep a written list of all the drugs and supplements you are taking, and
to periodically review this list with your doctors.

And always be sure that you understand the dose of the medicine being prescribed for you and how many pills
you are expected to take each day. Your doctor should tell you this information. When you fill a prescription
at the pharmacy, or if you get it by mail, you may want to check to see that the dose and the number of pills
per day on the pill bottle match the amounts that your doctor told you.

How We Picked the Best Buy Drugs

Our evaluation is based in part on an independent
scientific review of the studies and research literature
on muscle-relaxant drugs conducted by a team
of physicians and researchers at the Oregon Health &
Science University Evidence-Based Practice Center.
This analysis reviewed more than 120 studies,
including 59 trials of muscle relaxants for treating
spasticity, 52 for treating musculoskeletal conditions,
nine systematic reviews and three meta-analyses.
The analysis also included studies conducted by
the drugs' manufacturers. This effort was conducted
as part of the Drug Effectiveness Review Project, or
DERP. DERP is a first-of-its-kind 11-state initiative
to evaluate the comparative effectiveness and safety
of hundreds of prescription drugs.

A synopsis of DERP's analysis of the muscle-relaxant
drugs forms the basis for this report. An additional literature
search was conducted to capture the most
recent published studies available on muscle relaxants.
A consultant to Consumer Reports Best Buy
Drugs is also a member of the Oregon-based research
team, which has no financial interest in any pharmaceutical
company or product. The full DERP review of
the muscle-relaxant drugs is available at http://www.ohsu.edu/ohsuedu/research/policycenter/DERP/about/final-products.cfm. (This is a long and technical
document written for physicians.)

The monthly costs we cite were obtained from a
health-care information company that tracks the
sales of prescription drugs in the U.S. Prices for a
drug can vary quite widely. All the prices in this
report are national averages based on sales in retail
outlets. They reflect the cash price paid for a
month's supply of each drug in August 2009.

Consumers Union and Consumer Reports selected
the Best Buy Drugs using the following criteria. The
drug had to:

Be approved by the FDA to treat muscle spasticity or spasms.

Be as effective as or more effective than other muscle relaxant medicines when prescribed appropriately according to FDA guidelines.

Have a safety record equal to or better than other muscle relaxant medicines when prescribed appropriately.

The Consumers Reports Best Buy Drugs methodology
is described in more detail in the Methods section at
CRBestBuyDrugs.org.

Sharing This Report

This copyrighted report can be freely downloaded, reprinted, and disseminated for individual noncommercial
use without permission from Consumers Union or Consumer Reports® magazine as long as it clearly
attributed to Consumer Reports Best Buy Drugs™. We encourage its wide dissemination as well, for the
purpose of informing consumers. However, Consumers Union does not authorize the use of its name or
materials for commercial, marketing, or promotional purposes. Any organization interested in broader distribution
of this report should contact Wendy Wintman at wintwe@consumer.org. Consumer Reports Best
Buy Drugs™ is a trademarked property of Consumers Union. All quotes from the material should site
Consumer Reports Best Buy Drugs™ as the source.

About Us

Consumers Union, publisher of Consumer Reports magazine, is an independent and nonprofit organization whose
mission since 1936 has been to provide consumers with unbiased information on goods and services and to create
a fair marketplace. Its website is www.consumer.org. The magazine's website is www.consumerreports.org.

Consumer Reports Best Buy Drugs is a public-education project administered by Consumers Union. Two outside
sources of generous funding made the project possible. They are a major grant from the Engelberg Foundation, a
private philanthropy, and a supporting grant from the National Library of Medicine, part of the National Institutes
of Health. A more detailed explanation of the project is available at CRBestBuyDrugs.org.

We followed a rigorous editorial process to ensure that the information in this report and on the Consumer
Reports Best Buy Drugs Web site is accurate and describes generally accepted clinical practices. If we find,
or are alerted to, an error, we will correct it as quickly as possible. But Consumer Reports and its authors,
editors, publishers, licensers, and any suppliers cannot be responsible for medical errors or omissions, or
any consequences from the use of the information on this site. Please refer to our user agreement at
CRBestBuyDrugs.org for further information.

Consumer Reports Best Buy Drugs should not be viewed as a substitute for a consultation with a medical
or health professional. This report and the information on CRBestBuyDrugs.org are
provided to enhance your communication with your doctor, rather than to replace it.

Cost Comparison of Muscle Relaxants

Note: If the price box contains a , that indicates the dose of that drug is likely available for a low monthly cost through discount
programs offered by large chain stores. For example, Kroger, Sam's Club, Target, and Walmart offer a month's supply of selected generic
drugs for $4 or a three-month supply for $10. Other chain stores, such as Costco, CVS, Kmart, and Walgreens, offer similar programs.
Some programs have restrictions or membership fees, so check the details carefully for restrictions and to make sure your drug is covered.

Narrow your list

Best Buy recommendations only

Generic only

Low monthly cost program availability

Brand Name only

Spasticity only

Spasms only

OTC only

Rx only

CRBest Buy

Generic Name and Dose

Brand Name

Typical dosing schedule 1

Approved indication 1

Average cost per 30 days of use (for spasticity) or per 7 days of use (for muscle spasms) 2

1

Baclofen 10 mg tablet

Generic

Three times daily

Spasticity

$27

1

Baclofen 20 mg tablet

Generic

Three times daily

Spasticity

$60

Carisoprodol 250 mg tablet

Soma

Three times daily

Spasms

$84

Carisoprodol 350 mg tablet

Soma

Three times daily

Spasms

$147

Chlorzoxazone 500 mg tablet

Parafon Forte DSC

Three-four times daily

Spasms

$63-$84

Chlorzoxazone 500 mg tablet

Generic

Three-four times daily

Spasms

$8-$11

Cyclobenzaprine 5 mg tablet

Flexeril

Three times daily

Spasms

$42

Cyclobenzaprine 10 mg tablet

Flexeril

Three times daily

Spasms

$42

Cyclobenzaprine 7.5 mg

Fexmid

Three times daily

Spasms

$105

1

Cyclobenzaprine 5 mg

Generic

Three times daily

Spasms

$15

1

Cyclobenzaprine 10 mg

Generic

Three times daily

Spasms

$8

Cyclobenzaprine 15 mg continuous delivery capsule

Amrix

Once daily

Spasms

$91

Cyclobenzaprine 30 mg continuous delivery capsule

Amrix

Once daily

Spasms

$91

Dantrolene 25 mg capsule

Dantrium

Three-four times daily

Spasticity

$138-$184

Dantrolene 50 mg capsule

Dantrium

Three-four times daily

Spasticity

$165-$220

Dantrolene 100 mg capsule

Dantrium

Three-four times daily

Spasticity

$231-$308

Dantrolene 25 mg capsule

Generic

Three-four times daily

Spasticity

$111-$148

Dantrolene 50 mg capsule

Generic

Three-four times daily

Spasticity

$153-$204

Dantrolene 100 mg capsule

Generic

Three-four times daily

Spasticity

$198-$264

Metaxalone 400 mg tablet

Skelaxin

Three times daily

Spasms

$42

Metaxalone 800 mg tablet

Skelaxin

Three times daily

Spasms

$105

Methocarbamol 500 mg tablet

Robaxin

Four times daily

Spasms

$56

Methocarbamol 750 mg tablet

Robaxin-750

Four times daily

Spasms

$56

Methocarbamol 500 mg tablet

Generic

Four times daily

Spasms

$11

Methocarbamol 750 mg tablet

Generic

Four times daily

Spasms

$14

Orphenadrine 100 mg tablet

Norflex

Twice daily

Spasms

$42

Orphenadrine 100 mg tablet

Generic

Twice daily

Spasms

$28

Tizanidine 2 mg tablet

Zanaflex

Three times daily

Spasticity

$195

Tizanidine 4 mg tablet

Zanaflex

Three times daily

Spasticity

$249

Tizanidine 2 mg capsule

Zanaflex

Three times daily

Spasticity

$249

Tizanidine 4 mg capsule

Zanaflex

Three times daily

Spasticity

$324

Tizanidine 6 mg capsule

Zanaflex

Three times daily

Spasticity

$486

Tizanidine 2 mg tablet

Generic

Three times daily

Spasticity

$81

Tizanidine 4 mg tablet

Generic

Three times daily

Spasticity

$72

Carisoprodol/aspirin 200/325 mg tablet

Carisoprodol CPD

Three times daily

Spasms

$42

Carisoprodol/aspirin/codeine 200/325/16 mg tablet

Carisoprodol CPD with codeine

Three times daily

Spasms

$42

Methocarbamol/aspirin 400/325 mg tablet

Generic

Three times daily

Spasms

$13

Orphenadrine/aspirin/caffeine 50/770/60 mg tablet

Norgesic forte

Three times daily

Spasms

$63

Orphenadrine/aspirin/caffeine 25/385/30 mg tablet

Orphenadrine compound

Three times daily

Spasms

$42

Orphenadrine/aspirin/caffeine 50/770/60 mg tablet

Orphenadrine compound

Three times daily

Spasms

$63-$84

As typically prescribed. The dose ranges and the drug's FDA approved indication are derived from drug-labeling information.

Prices reflect the nationwide retail average for August 2009, rounded to the nearest dollar. Information is derived by Consumer Reports Best Buy Drugs from data provided
by Symphony Health Solutions, which is not involved in our analysis or recommendations.

We're sorry, an error occurred.

Thank you for your feedback. Your health and well being are important to us. We're sorry you couldn't find the information you were looking for this time, but your comments will help us identify gaps and improve our content.

We applaud you for taking an active role in your health!

To your health,
The Healthline Team

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